California Insurance Lawyer Blog

A recent CBS News segment relates the story of Timber Harwood, a 93-year-old long-term care insurance policyholder fighting Bankers Life for benefits after he was seriously injured in a fall and needed the care of an in-home health aide. See “Some long-term healthcare policies not paying up,” http://www.cbsnews.com/8301-500202_162-57352805/some-long-term-healthcare-policies-not-paying-up/.

For more than a year, Bankers Life repeatedly “lost” or “misplaced” hundreds of pages of Harwood’s documents supporting his need for benefits while he used his life savings to pay for care. Things improved when Harwood’s niece – Kansas’s top insurance regulator – stepped in to help. Bankers Life eventually paid his claims, but then concluded he is “too healthy” to need in-home care, so the benefits stopped. Harwood and family are so worn down by the process they have decided not to pursue benefits.

The report concludes that LTC insurance isn’t paying as advertised and that customers should expect hefty premium increases.

We have also witnessed Bankers Life (and other LTC carriers’) claims handling practices, and have sued them to force them to pay. In our opinion, the worst thing a family can do is to give up the fight and let the carriers get away with not paying the benefits they owe.

Many people are successfully fighting their LTC carriers for benefits. Some of them have had to hire contingency fee lawyers like us to do it, but they made the decision that it’s more sensible to attempt hold their insurer accountable then spend their life savings on care they paid an insurance company to provide for.

Every LTC carrier is going to make you prove you need benefits, and some won’t make the task easy. Others will make the process discouraging and next to impossible. When that happens, find someone who understands how to deal with LTC insurers to help you. Most people aren’t as lucky as Mr. Harwood was to have an insurance regulator in the family to come to the rescue. Still, family members can help by calling and writing letters to the insurance company and demanding that they act expediently. Complain to the insurance commissioner of your state if the company does not respond to your inquires, or is acting irresponsibly. Usually, squeaky wheels get the grease. If all else fails, find an attorney with experience in this area.

We sincerely hope Mr. Harwood is indeed too healthy to need LTC benefits, but if he isn’t he shouldn’t give up the fight. And no one should. If Bankers Life or any other insurance carrier has denied your benefits, fight for your rights and make them pay what they owe!

Kantor & Kantor partners Glenn Kantor and Corinne Chandler will present a National Business Institute teleconference “Troubleshooting Long Term Care Insurance Claims,” Thursday, January 26, 2012, at 10:00 a.m. Pacific time. The presentation, designed for a national audience of lawyers seeking to expand their knowledge about claims-handling practices and litigation strategies, provides up to two hours of continuing education credit. Topics the program covers include an overview of the state of the long-term care insurance industry, how to analyze common long-term claims and benefits denials, and creative litigation tactics.

For more information, or to register, follow this link: http://www.nbi-sems.com/SemTeleDetails.aspx/R-58789ER%7C?ctname=SPKEM.

The National Business Institute is one of the nation’s largest providers of legal and professional education, serving over two million professionals.

Kantor & Kantor is one of the largest law firms in the country exclusively representing plaintiffs who have been denied insurance benefits from life, health disability and long-term care policies. The firm has extensive experience with the complex appeals process and federal court litigation of ERISA matters. For more information, call (800) 446-7529.

PRESS RELEASE:

LOS ANGELES, October 31, 2011 -- Kantor & Kantor, LLP announced today that lawyers Alan Kassan and Corinne Chandler are presenters at the 21st Annual Western Region Chapter of the National Association of Professional Geriatric Care Managers held at the Bellagio Hotel in Las Vegas November 3-5. The session, “Obtaining Insurance Benefits for Your Client’s Care,” is scheduled for Friday, November 4, at 2:15.

“Many people purchased long-term care insurance decades ago and before many of today’s senior care options were even contemplated,” said Mr. Kassan, a Kantor & Kantor partner who sues insurance companies on behalf of individuals denied long-term care. “As a result, since most many present care options are not enumerated in polices, and insureds have to appeal or litigate to ensure benefits for the most appropriate long-term care. Part of what we do is educate professionals in the geriatric care industry about how to understand insurance policy language and to help their clients with the legal process.”

A common reason LTC carriers deny benefits is because the policyholder resides in an assisted living facility but the 20-year-old policy doesn’t cover such facilities, which were not an option until recent years. Kantor & Kantor has successfully litigated the issue, allowing policyholders to receive benefits for assisted living.

“As the Baby Boomer population ages and requires care, we expect more options to arise for which insurers will deny coverage,” said partner Corinne Chandler. “When geriatric care professionals understand that insurance companies don’t always have the last word, they can better help their clients navigate the often complex long-term care legal environment."

About Kantor & Kantor, LLP
Kantor & Kantor is one of the largest law firms in the country exclusively representing plaintiffs who have been denied insurance benefits from life, health, disability and long-term care policies. The firm has extensive experience with the complex appeals process and federal court litigation of ERISA matters. For more information, log on to www.kantorlaw.net, call (800) 446-7529, or follow the firm at www.californiainsurancelawyerblog.com.

Results from the latest field poll conducted by the California Partnership for Long-Term Care are not surprising. Although more people are aware they will likely need long-term care benefits in the future, fewer are purchasing policies. See, “Californians Know They Need Long Term Care Coverage, But Don’t Buy It.”

According to the survey, state residents purchased 22,000 fewer policies in 2008 than they did in 2000. About 30 percent of the respondents expressed concerns that insurance companies would fail to honor their policies as their chief reason for not purchasing LTC insurance.
That’s a legitimate concern, as we well know.

Do your research and choose a reputable company offering the best policy you can afford. While the LTC component of President Obama’s healthcare overhaul (aka the CLASS Act) may offer some attractive alternatives for some, be aware that experts predict the launch will be delayed by as much as a year as the administration tries to create an inexpensive yet sound program.

If and when the time comes you have to fight for Long Term Care insurance benefits, call us to hold your insurer accountable.

For more information about obtaining LTC benefits after delays or denials, call 800-446-7529.

From 2009, to 2010, United Healthcare cut in half the compensation of its Chief Operating Officer, Stephen J. Hemsley. At first blush, it would appear United Healthcare is recognizing the ballooning costs to consumers of healthcare, and it acting responsibly. First looks can be deceiving. See http://blogs.courant.com/connecticut_insurance/2011/04/unitedhealth-ceos-pay-dropped.html

In 2009, Hemsley received $102 million in total compensation from United Healthcare. In 2010, his pay was cut in half, but even after a 50% reduction, he still received an exorbitant $48.8 million dollars in compensation. The majority of this pay was in the form of stocks and stock options ($ 44 million), in addition to the $4.8 million in he was paid in salary, incentive pay, and other compensation. Putting his compensation into perspective, his 2010 compensation is equal to the sum total of the average annual household income of 2,000 American households. It would also be enough to pay a $500 monthly health insurance premium for 8,500 families. See http://www.moneytalksnews.com/2010/04/17/insurance-outrage-hike-prices-pay-ceo-100000000/

How can United Healthcare justify its continued premium increases, based on rising healthcare costs, while at the same time paying its Chief Executive $48,800,000? Shouldn’t the Board of Directors of United Healthcare be more concerned with its policyholders’ ability to access and receive quality care rather than compensating its officers in such an outrageous manner?
Andrew Goldstein of corporate compensation adviser Towers Watson says, “We all kind of scratch our heads when executives are making millions, and (corporate) directors feel obligated to give them $10,000 for financial planning, It’s not like directors haven’t thought about getting rid of perks. They’re still a sticking point for a lot of executives. They feel it’s part of their compensation package. And it’s a stature thing.” So it seems that despite these tremendous salaries, CEO’s continue to cling to these perks at the health expense and financial burden of those less fortunate. Simply because directors feel obligated, and executives feel entitled. See http://www.usatoday.com/money/companies/management/2011-04-11-CEO-perks.htm

While families struggle to afford the soaring increases in insurance rates and battle the stresses of paying for prescriptions, doctor visits, and various health issues, United Healthcare remains “America’s largest commercial health insurer based upon revenue”, seemingly profiting from our medical woes. If it wasn’t so sad, and if so many Americans were not suffering from the consequences of being uninsured, classifying compensation of $49 million dollars as “pay cut,” would be comical. Perhaps the various departments of insurance, and our legislature, should look a lot more closely at insurance executive compensation when considering how to regulate insurance costs and fix our insurance crises.

Our client, Mr. D, was a technician for a large energy company, wherein his job duties involved heavy maintenance duties. He suffered a stroke in March 2007, was hospitalized, and underwent extensive rehabilitation and physical therapy to learn to walk and function again. CIGNA paid disability benefits for just over 2 years, until it wrongfully terminated benefits, claiming that Mr. D was again capable of working. In support of its decision, CIGNA relied upon a two and a half hour Functional Capacity Evaluation (FCE), which reported that Mr. D could return to full time work. Despite the fact that FCE confirmed his dizziness, vertigo and continuing symptoms, CIGNA determined that he could return to work as a customer service clerk or a telephone clerk.
Mr. D advised Cigna that he was unable to perform these occupations because, among other things, the stroke had impaired his vocal cords. However, Cigna ignored this impairment. Finally, we filmed a video of our client attempting to perform some of the tasks which Cigna claimed he could do. Based upon this film and the medical evidence we submitted in support of the claim, Cigna reversed its claim decision and approved Mr. D’s continuing benefits.

The New York Times reported this morning on a very disturbing trend. It seems various states are relaxing their laws which require insurance companies to maintain adequate reserves to pay claims, and to keep their finances transparent to the public. Why in the world would state governments do such a thing? Well, it seems there is money to be made in the form of taxing these insurance entitles...a lot of money. So, "shady" business that was mainly being conducted offshore in countries like Bermuda or the Cayman Islands, is now permissible in states like Vermont, Utah, South Carolina, Delaware and Hawaii. Those states are "aggressively remaking themselves as destinations of choice for the kind of complex private insurance transactions once done almost exclusively offshore. Roughly 30 states have passed some type of law to allow companies to set up special insurance subsidiaries called captives, which can conduct Bermuda-style financial wizardry right in a policyholder’s own backyard."

Aetna, MetLife, the Hartford Financial Services Group, Swiss Reinsurance, Genworth Financial and the American International Group (A.I.G.), among others, taken advantage of these laws and the concept of "captives" in order to refinance life, disability and long-term-care insurance policies.

One of the major concerns of these financial maneuverings is that is that some states are offering a more lenient, and less protective scheme of laws than other states and thus lure companies away from the protective states. This game may allow insurance companies to escape some of the consumer protective rules that have been put in place over the course of many years, all to the detriment of insurance consumers.

Fortunately, our California Insurance Commissioner, Dave Jones, is taking a cautious and sensible approach to all of this as can be seen from his comments. Mr. Jones remarks “we need to ensure that innovative transactions are not a strategy to drain value away from policyholders only to provide short-term enrichment to shareholders and investment bankers.”

Read the original article. It's a bit scary. http://www.nytimes.com/2011/05/09/business/economy/09insure.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=tha2

The California Association for Health Services at Home (CAHSAH) is the leading statewide home care association in the nation and the voice of home care for the western United States. CAHSAH represents more than 537 members and 850 offices that are direct providers of health and supportive services and products in the home. Next month, May 10-12 CAHSAH will hold their annual conference in Ontario California.

Kantor & Kantor Partners, Glenn Kantor and Corinne Chandler will have the honor of addressing CAHSAH members during an educational session to speak on issues related to long term care and insurance. The session will take place on Wednesday, May 11, 2011, 10:15:00 AM - 11:45:00 AM.

Mr. Kantor and Ms. Chandler will address the reasons insurance companies deny long-term care benefits. They will also discuss the importance of anticipating denials, understanding the policy language and limitations, having all necessary documentation and support letters to include with the claim, and communicating with the insurer in a manner that will establish a record if appeal or litigation becomes necessary.

Our lawyers are frequently called upon to speak at organizational events and we pride ourselves on being in a position to help people not only understand their health related insurance benefits, but to also help them obtain those benefits when they have been wrongfully denied.

For more information on CAHSAH and the Conference, click here: http://www.cahsah.org/?p=annual_conferences

We continue to see evidence in insurance company claim files that insurers are not only conducting traditional surveillance, following their insureds/our clients around, but the insurers are using the internet to snoop around and learn as much as they can about claimants, their activities, their family members, etc.

We know the insurance companies do this to protect against fraud, and there is nothing wrong with that. But, all too often, the insurers get a bit overzealous, and even intrusive in their conduct, and they start to treat everyone like a criminal of some sort.

Perhaps the most shocking example of this activity we’re aware of, is a case of one major insurer accessing private files off of a claimant’s computer. It appears that the insurer may have actually hacked into its insured’s private computer to obtain information related to internet activities, e-bay purchases, YouTube viewing history and private files.

Such activity is, of course, illegal, and may give rise to, among other things, an invasion of privacy cause of action. We continue to remind our clients and anyone with insurance who may or may not ever make an insurance claim: do not take internet privacy for granted. While it is one thing for an insurance company or any other entity or individual to illegally access your private information, it IS legal for anyone to track your internet activities you put in the public sphere of cyberspace. Be mindful that what you post, blog about, advertise, or share on social networking sites, message boards, in online fora, etc. is fair game. Moreover, the reality is often that the picture one portrays of him or her self in cyberspace, may not be a complete picture of that person's life. Unfortunately, when it comes to insurance claims, and particularly ERISA claims, such a picture may be the only one a court sees. Be mindful.

One of California’s largest health insurers -Blue Shield- has announced plans to hike its premiums by as much as 59%. These increased premiums are set to take effect on March 1, 2011. This move impacts 193,000 individual Blue Shield policy holders.

This steep double digit rate hike has raised the attention of Health and Human Services Secretary Kathleen Sebelius who has reached out to newly elected California Insurance Commissioner Dave Jones. “We stand ready to assist him and the people of California in any way that we can”, she stated. She went on to state, “The people of California have a right to be concerned when they see this kind of rate increase month after month.”

Commissioner Jones recently won a hard fought race for his position and on January 3, 2011 announced that rejecting excessive health insurance premiums and continuing his fight for the authority to reject these premiums are among his main priorities for his time in office. However, as he stated in his inaugural address, “Many Californians will no doubt be surprised to learn that the Insurance Commissioner does not have the legal authority to reject excessive health insurance premium increases.” Unfortunately, despite health reform, even the federal government does not have the authority to review and strike down unreasonable rate increase requests.

Instead, Commissioner Jones has requested that Blue Shield delay implementation of the rate hike so that he and state regulators have the opportunity to fully review the increase. In a statement on January 6, 2011, Jones said, “I find it stunning that Blue Shield would seek to impose such massive premium increases on policyholders during these troubling economic times....[T]hese premium increases will impose significant financial burdens on struggling families and, in some cases, will lead to the loss of health care coverage all together.”

This is just the first fight of many that Commissioner Jones will face with the insurance industry. In his inaugural address, he identified his main objective as “making the California Department of Insurance the strongest consumer protection agency in the nation” and to “set the standard for other consumer protection agencies.” His three main priorities are:

1. To implement federal health care reform and build on that reform by granting the insurance commissioner the authority to reject excessive premium increases;
2. To level the playing field for consumers and business as they deal with insurance companies...to make sure that consumer complaints are being addressed and that insurance companies are not taking advantage of consumers; and
3. Ensuring that California has a viable and competitive insurance market.

To implement his first priority, Commissioner Jones has created a new senior leadership position titled, “Deputy Commissioner for Health Care Policy and Reform.” He will continue the efforts to provide the commissioner and the Department of Managed Care the legal authority reject excessive health care premiums and he will see to it that he has the legal authority to enforce the new federal health care reform. Jones has already signed an emergency regulation giving him the authority to enforce in California, the new federal 80% medical loss ratio for the individual health insurance market. Existing California law requires insurers to spend at least 70% of premiums from the individual market on medical care. Jones’ proposal aligns California’s regulations with the national Medical Loss Ratio rules established under the federal health reform law that took effect on January 1, 2011.

The next four years under Insurance Commissioner Jones promise to be one of the most consumer oriented terms ever in California. It will be a challenge to deal with the special interests of the insurance carriers while working to protect the rights of California’s insureds. But so far, Dave Jones has demonstrated that he is ready to stand up to the insurers and protect consumers.

MetLife announced this month that it would stop selling Long Term Care (LTC) insurance. The company cited financial challenges with this segment of the insurance market.

According to the Wall Street Journal, MetLife is among the bigger sellers of the coverage, with about 600,000 policyholders, or about 8%, among the eight million who have long-term-care insurance in the U.S., according to the company and an industry trade association.

We suspect MetLife determined that Long Term Care insurance will have significant, and increasingly greater numbers of claims as the Baby-Boom generations age. To make the insurance profitable for the company, MetLife would have to charge much higher premiums than the current going rates. With widespread unemployment and a struggling economy, now is probably not the best time to sell a product that, to most, would be out of financial reach. Other companies are also obviously feeling the pain as they too are either scaling back their LTC offerings or seeking approval for drastic premium increases in order to stay financially healthy in view of present and anticipated claims experiences.

What does all of this mean to you, the individual who is either contemplating the purchase of such insurance, or worse, dealing with an LTC benefit denial? It means the carriers aren't very good at underwriting this risk, and so they will probably continue to jack up premiums, and deny benefits wherever they can. Buckle up, and proceed with caution and care. In the case of claims, seek legal advice at the first signs of your insurance company giving you trouble, or making repeated or burdensome demands to support your claim.

...Premium Increases

Long term care insurance has become a staple for many individuals and couples entering their "golden years." Insurance companies have been rather active in their quest to capture the market of the aging baby boomers looking to ensure that they are cared for in their old age. And, the market is huge. The idea of long term care insurance actually makes a lot of sense for those who can afford it. What consumers didn't (and don't) bank on, is that the cost of such insurance can be highly uncertain. The premium payments quoted at the time of sale, may be more of a "loss leader" than a sign of what the insurance will cost you over your lifetime. Take the case of Mr. and Mrs. Vargo who were the subject of a recent Wall Street Journal article. They bought insurance in 2002 from Lincoln Benefit Life, a subsidiary of Allstate Corp with premiums at $3,305. This September they were advised that premiums would increase to $4,868, a 47% increase.

This is becoming more and more common. The Wall Street Journal also reported that John Hancock Financial was seeking an average 40% increase for about 850,000 of its 1.1 million policyholders. The insurer, a unit of Manulife Financial Corp., also stopped sales of new long-term-care plans to employer-benefits programs.

Other companies including American International Group Inc., MetLife Inc. and Lincoln National Corp. have also recently applied for or received approval for rate rises ranging from 10% to 40%.

Why are premiums going up so much? That's the crazy thing...carriers say it is because "more people used the insurance than anticipated." Insurance companies are in the business of assessing risk. It's what they do. It seems much more likely that carriers lured people into the world of long term care coverage by selling the idea of a secure old age with low rates, and then, after collecting years of premiums, raise rates so high that the insurance gets dropped, and they never have to pay benefits. We haven't seen any evidence of this, but it just doesn't seem reasonable that insurers could have all made such huge errors in their analysands. You can judge for yourself what you think is going on here. The point is, beware! When buying, or renewing long term care coverage, try to get some assurances that you are dealing with a reputable company. Get a history of premium increases. Inquire about fixed premiums. Inquire about any planned future premium increases, or outstanding requests. Get everything in writing. At a minimum these are the things you need to do to protect your interests.

Some things make no sense. Consider the following where a bill to protect California consumers passes the legislature by an overwhelming majority, has no adverse fiscal impact on the State whatsoever, yet get's vetoed by the Governor with an explanation that cannot be justified....

FOR IMMEDIATE RELEASE
Sept. 30, 2010
Contact: Chris Shultz, 916-319-2009 office, 916-601-2521 mobile

Dave Jones’ legislation to ban “discretionary clauses” in life and disability insurance policies vetoed by Governor

Veto maintains playing field tilted against consumers

SACRAMENTO – Today the Governor vetoed legislation by Assemblymember Dave Jones (D-Sacramento) to help injured workers get a fair hearing when fighting insurance companies in court.

Assembly Bill 1868 would have banned discretionary clauses in life and disability insurance policies, and leveled the playing field between insurance companies and consumers by ensuring that individuals who have been denied benefits by their insurance companies get a fair hearing in court.

“These discretionary clauses reserve authority to insurance companies to determine benefits and policy interpretation,” said Jones. “Prohibiting discretionary clauses would have leveled the playing field between insurance companies and consumers by simply ensuring that individuals who have been denied benefits by their insurance companies get a fair hearing in court. Once again, the Governor sides with insurance companies and against reform.”

Discretionary clauses reserve authority to insurance companies to determine benefits and policy interpretation. Inclusion of these clauses in insurance policies has the effect of lessening the intensity of judicial review in claims denial cases to an “abuse of discretion” standard, which is an insurmountable standard for consumers to meet.

Under current law, insurance company decisions to deny benefits are upheld as long as they are grounded in any reasonable basis, even when a judge is convinced the plaintiff is in fact disabled. This is in direct conflict with a basic principle of California law that contracts are interpreted against the drafter, and not against unsophisticated consumers who do not have the opportunity to bargain for favorable terms in their employer-provided insurance policies.

The State Senate approved the bill 23-12 and the bi-partisan vote in the Assembly was 64-11.

This post comes from a recent forum discussion Q&A with Glenn Kantor:

Q: My policy states that I can go to arbitration if I disagree with the answer to my appeal of a Long Term Disability claim. But the insurance company only mentioned a civil suit as my option if I want to dispute their denial. What’s the difference between going to arbitration and bringing a civil suit? Won’t arbitration cost less and be less complicated?

A: Bringing a civil suit means filing a lawsuit in U.S. District Court and having a Federal Judge decide your case. Arbitration is outside the judicial system and is private. It can be binding or non-binding, binding with a right to appeal, or totally binding with a waiver of any appeal rights.

In a Federal Court action, other than a filing fee, there are no “costs” associated with proceeding to Judgment -- at least no costs which need to be paid to the Court.

A private arbitrator will expect to be paid. Sometimes the insurance carrier or employer will agree to pay the arbitrator. However, do you want to take part in a proceeding where the party deciding the case knows that someone else paid his bill? (Although arbitrators should not have such information, they often do.) The desire for repeat business from the insurer or employer MIGHT impact the decision, even if only subconsciously.

In the world of ERISA litigation, outcomes frequently depend on the judicial temperament of the Judge. If I could PICK the judge to whom my client’s case was to be assigned, I would always suggest a Federal lawsuit. In most jurisdictions, however, cases are randomly assigned to a judge from a pool that can be as small as two Judges or, if you are in a city such as Los Angeles, more than 30 Judges. For that reason, if the defendants are willing to select an arbitrator I have agreed to, I might be inclined to advise my client to agree to arbitration.

No lawyer could decide which option is better without a lot more information about the particulars of the case, and even then, there are so many variables involved that it is impossible to know for sure which dispute resolution methodology will more likely result in your receiving benefits.

If you are at the stage where your appeal has been denied, and you need to either file suit or agree to arbitration, please don’t make any decisions until you have discussed the matter with counsel.

The American Association for Long-Term Care Insurance reported this month the results of a study that analyzed the cost of long-term care insurance for typical purchasers. Most people under age 61 pay from $500 to $1500 a year, much less than what many people think such insurance will cost. That works out to less than $20 a week for most wage-earners, said AALTCI executive director Jesse Slome.

The report also provide tips about how to further reduce the cost of premiums, including trying to qualify for a preferred health discount, selecting a 90-day elimination period, chooses a spousal “share-care” option, and shopping around among carriers for the best coverage at the most affordable rate.

It might be easy to dismiss this study as self-interested, since the AALTCI, according to its web site serves “those who offer long-term care insurance and other planning solutions.” In addition, the timing is suspicious, the report arriving just months after passage of the CLASS Act, the part of the federal government’s healthcare reform package that will create a voluntary government-run long-term care insurance program. Average premiums under that program are estimated to start at $100 to $240 a month ($1200 to $2880 a year) and pay out a mere $50 to $75 a day – too much for too little, some critics have said.

Nevertheless, this report may be an indication that the LTC industry is working swiftly to get ahead of the government program by creating highly competitive long-term care products. And if there is going to be an LTC price war, now might be the time – no matter what your age – to purchase coverage.

As we frequently note in this blog, LTC coverage is about the only option for people who must pay for in-home or assisted living care when they are ill or aged. Work with a reputable agent who can find you the right policy with a well-capitalized carrier. Research what care cost will be by the time you could need it, and plan accordingly. Although in the end you may have to fight with your carrier to receive benefits, it’s better to have that option than none at all.

To examine the report go to http://www.aaltci.org/news/long-term-care-association-news/report-what-people-pay-for-ltc-health-insurance.

Do you, or does someone you know have a Long Term Care Policy from a n insurance company that refused to pay benefits? Was that denial based upon the fact that the agency providing care was not "licensed" or "approved?" We are seeing this more and more, and we are suing these companies on behalf of our clients.

The insurance companies twist the language of these policies so as to argue that care providers must be licensed by the State of California. The fact is, however, California does not require licensing for certain classes of care providers, and they couldn't get licensed by the state even if they wanted to! Most of these policies contain provisions which pay for "Home Health Care Services," or services from a "Home Health Care Agency." Sometimes, the benefits are characterized as "Personal Care Services" or "Instrumental Activities of Daily Living."

Companies we've seen denying benefits on grounds the agency is not licensed include Conseco Senior Health, Senior Health Insurance Company (SHIP), Transport Life, American Travelers Life and others.

Don't let these companies get away with not paying you benefits! Call us. We don't charge for an initial interview, and if we take the case, it will be on a contingency, so you won't have to pay attorneys fees on an hourly basis.

800-446-7529

The new federal healthcare legislation could bestow broad new powers on California’s next insurance commissioner, already one of the nation’s most powerful jobs of its kind, reports the Los Angeles Times. “Healthcare reform raises the stakes in California insurance commissioner election.” Four candidates are running for their parties’ nominations in the June 8 primary election -- Democrats Dave Jones and Hector De La Torre, and Republicans Brian D. Fitzgerald and Mike Villines – and the winner of the June 8 primary will face four other minor party candidates in November.

In addition to new authority under federal law, the insurance commissioner may gain the regulatory powers currently under the charge of the California Department of Managed Healthcare, which oversees health maintenance organizations, if the Legislature approves and the governor signs a bill that would shift all regulatory power to the commissioner.

This year’s insurance commissioner race is one of the most important in the state’s history.

We support Democrat Dave Jones, who proved a strong consumer advocate while serving as a California Assemblymember. In addition to supporting the regulatory shift from the Department of Managed Healthcare, Jones wants California lawmakers to give the commissioner the power to approve or reject insurer requests for rate increases, subjecting health insurance rates to the same detailed approval process that applies to automobile, home and other types of property and casualty insurance.

“I’ll be working to impose rate regulation on health insurance and healthcare plans to rein in the excessive rate increases that have afflicted California consumers year after year for the past 10 years,” Jones told the Times.

We believe Jones has the experience, leadership skills and ability to protect consumers as insurance commissioner, as well as hold insurance companies accountable when they break the law or deny benefits their customers rightfully deserve. From what we have seen thus far, he is fully capable of fulfilling the challenges facing the state and the insurance industry during the next four years and of building a bureaucracy that works in the consumers’ interests.

Los Angeles Times business columnist Michael Hiltzik recently wrote about retired state employees who purchased a long-term care insurance policy in 1997. Unfortunately, like many others who had purchased long term care insurance years ago, the couple could no longer afford the insurance because premiums had increased 100 percent. See, “Long-Term Care Policies: Pouring Money Down a Hole?” http://www.latimes.com/business/la-fi-hiltzik7-2010apr07,0,7567632.column.
Many people who believed they were responsibly planning for the future by purchasing long-term care insurance in the late 1980’s or early 90’s are encountering this problem: Almost every insurer selling long-term care products at that time underpriced their policies. As a result during the past decade, these carriers have successfully obtained approval from state agencies to raise the premiums for their products. It is not unusual for a premium increase to be 40 percent to 50 percent of the original price. Unfortunately, these increases come at a time when many of the policyholders are now on a fixed income and cannot afford the increased cost.
Policyholders who purchased policies before 1993 may have another critical but less publicized issue in addition to substantial premium increases: outdated protection. If policyholders purchased “nursing home” only policies, their insurance carriers will likely contend the policies do not cover the more popular assisted living facilities.
Additionally, a policyholder may have purchased a “home healthcare” benefit policy, which is intended to pay for services rendered by a home healthcare aide in one’s “home.” Although an insured may have relocated his or her residence to an assisted living facility, a carrier may not pay because it contends that the facility is not the insured’s “home.”
At Kantor & Kantor, we provide assistance to those policyholders who have been unfairly denied benefits under long-term care policies, and we have successfully argued that benefits cover assisted living facilities. If your long-term care insurer has denied benefits based on policy language, we can help.

-CC

Although it’s much too soon to tell how the federal healthcare overhaul will affect the way the insurance industry conducts business, the bill may have done a few things right. “Immediate Effects of Health Reform Bill.” A few provisions go into effect in six months; others won’t be enforceable until 2014.

• People whose policies are rescinded through no fault of their own are now protected under federal law. Even though rescission is regulated under the law of most states, carriers tend to ignore the laws and do as they please until they are caught, then pay moderate fines. How the federal government will enforce this provision remains to be seen.
• People with pre-existing conditions can no longer be denied coverage; however, because the bill doesn’t regulate caps and increases, insurers can change as much as they want and increase when they feel like it. The federal plan does provide a government program for people whose health problems make them uninsurable now.
• Insurers can no longer place lifetime caps on benefits and annual limits on coverage.

If insurers don’t find a way to wriggle out of these three reforms, the bill imposes important measures that are necessary to rein in abusive industry practices. But we don’t expect the industry to embrace reform without a fight.

Rather than criticizing the bill for its flaws, which many say include an inability to contain costs, industry and enterprise could turn this into an opportunity to provide products and services both affordable and sustainable for this century.

The CLASS Act, the part of the federal healthcare overhaul that creates a payroll deduction for long-term care similar to Social Security, may survive to make it into the final version of a combined congressional bill and become law, writes James Oliphant in the Los Angeles Times.“Government Insurance for Long-Term Care Likely to Slip Into Final Healthcare Bill,” http://www.latimes.com/news/nation-and-world/la-na-health-longterm31-2009dec31,0,4138098.story.

Members of both the Senate and House of Representatives support the act, which is voluntary and requires payment into the plan for five years before a participant is entitled to receive benefits. The CLASS Act is also controversial.

Proponents, particularly those who lobby for the elderly and disabled, praise the act because it allows people the option to remain in their homes, paying for in-home caregivers without depleting the resources and energy of family members. Opponents believe the act won’t pay for itself and will require a government bailout to remain functional.

We believe the discourse about long-term care insurance – whether through the government plan or private insurance – is a necessary discussion to alert this country about a very important aspect of planning for the future. Whether the CLASS Act is the right solution, and whether it will even survive the House, remains to be seen.

Either way, it's our opinion that for the time being insurers need to reformulate their offerings and claims paying practices in order that people can obtain and afford, and then realize the benefits they need.